Mandibular fractures have been documented since ancient Greece. Hippocrates described reducing displaced but incomplete mandibular fractures by pressing on the lingual surface with fingers while applying counterpressure externally. The Edwin Smith Treatise also described examining for mandibular fractures by feeling for crepitus under the fingers. Mandibular fractures typically involve the body, angle, condyle, symphysis, or ramus. Physical exam may reveal changes in occlusion, inability to open or close the mouth, anesthesia of the lower lip, or trismus. Diagnosis is made by identifying these physical exam findings along with the patient's mechanism of injury.
3. HIPPOCRATES
“Displaced but incomplete
fractures of the mandible
where continuity of the bone is preserved
should be reduced by pressing the lingual
surface with the fingers
while counterpressure is applied from the
outside. Following the reduction,
teeth adjacent to the fracture are fastened to
one another using gold wire.”
4. THE EDWIN SMITH TREATISE
“If thou examinst a man having a fracture in his
mandible, thou shouldst place thy hand upon it…and
find that fracture crepitating under they fingers, thou
shouldst say concerning him: one having a fracture in
his mandible, over which a wound has been inflicted,
thou will a fever gain from it.”
The cause of death was believed to be sepsis
6. OVERVIEW
Accounts for over 50% of the
prehospital trauma deaths
encountered by prehospital
provider
Even when not fatal, head
injuries are devastating to
the survivor and family
Victims of significant head
injury seldom recover to the
same physical and emotional
state of pre-injury
Many victims suffer
irreversible personality
changes
7. MAXILLO-FACIAL TRAUMA
Causes -
MVA, home accidents,
athletic injuries, animal
bites, violence, industrial
accidents
Soft tissue -
lacerations, abrasions,
avulsions
vascular area supplied by
internal and external
carotids
Management -
Seldom life-threatening
unless in the airway
consider spinal
precautions
have suction available
and in control of
conscious patients
control bleeding
8.
9. FACIAL FRACTURES
Fx to the mandible,
maxilla, nasal bones,
zygoma & rarely the
frontal bone
S/S -
pain, swelling,
malocclusion, deep
lacerations, limited
ocular movement,
asymmetry, crepitus,
deviated nasal septum,
bleeding from orifice
Mandibular Fx -
malocclusion,
numbness, inability to
open or close the mouth,
excessive salivation
Anterior dislocation
extensive dental work,
yawning
Condylar heads move
forward and muscles
spasm
13. CAUSES OF JAW
FRACTURES
Falling onto face from a significant height
Gun shot wounds to the face
Motor vehicular accidents
Blow to the face
Weakening of the jaw caused by
Severe gum disease (periodontal disease) erosion of the jaw
bone
All meat diet
Supplementation with improper ratio of calcium and
phosphorus
Chronic kidney disease
Osteogenesis imperfecta - congenital disease
Cancer of the jaw bone
15. PATHOPHYSIOLOGY
Fractures result secondary to mechanical
overload.
Torque results in spiral fractures
avulsion, in transverse fractures
bending, in short oblique fractures
compression, in impaction and comminution.
16. PATHOPHYSIOLOGY:
Degree of fragmentation depends upon energy transfer
as a result of overload.
Therefore, wedge and multifragmentary fractures are
associated with higher energy release.
17. PATHOPHYSIOLOGY:
An evidence based study involving 3002 patients with
mandibular fractures…
the presence of a lower third molar may double the
risk of an angle fracture of the mandible.
18. PATHOPHYSIOLOGY:
Another study
compared fractures with wisdom teeth to those without.
Showed increased infectious risk (16.6%) in fractures
with wisdom teeth compared with 9.5% risk in
fractures without wisdom teeth.
19.
20. CLASSIFICATION OF
FRACTURES
Simple Fracture.
A simple fracture is a break in the bone that does not
produce an open wound in the skin.
complete or incomplete.
Tissue adjacent to the fracture may or may not suffer
considerable injury.
Also known as closed fracture
21. CLASSIFICATION OF
FRACTURES
Multiple - two or more fracture lines that are not
connected to each other.
Indirect - The fracture site is distant from the site of
injury.
Complex - there are considerable
Soft Tissue Injuries; this may be simple or
compound fracture
22. CLASSIFICATION OF
FRACTURES
Comminuted - involves splintered or crushed
bone.
Greenstick - also called incomplete fracture.
one cortex of the bone is broken
and the other cortex is bent
Atrophic - fracture resulting from severe
atrophy of the bone.
23. CLASSIFICATION OF
FRACTURES
Compound Fracture / Open fracture
with an external wound extending to the bone.
Communication is an invitation for contamination.
Fracture communicates with the external wound,
involving skin, mucosa, or periodontal membrane
Comminuted Fracture.
bone is splintered into three or more fragments or is
crushed.
NOTE: A compound-comminuted fracture is one
with both a splintering of the bone and a break in
the bone with an opening to the covering surface.
24. CLASSIFICATION OF
FRACTURES
Depressed Fracture.
fractured part is driven below the normal level of
the bone, as in a skull fracture.
Impacted Fracture.
hard cortical bone of one fragment is driven into
the softer cancellous bone of another fragment.
Pathologic (Spontaneous) Fracture.
break without external violence at an area of the
bone that has been weakened by a local disease.
25. CLASSIFICATION OF
FRACTURES
Multiple Fracture.
two or more fractures occur in the same or
different bones.
Favorable Fracture.
line of the fracture occurs in a direction that does
not allow the pull of the muscles on the segments
to displace the segments.
Unfavorable Fracture.
fracture with displacement or separation of the
fractured segments due to muscle pull on the
segments.
28. THE ANGLE
CLASSIFICATION
Based upon the relationship of the first mandibular
and maxillary molars
Class I: normal occlusion
Class II: an “underbite”
Class III: an “overbite”
Observe wear facets
31. Class I: (normal)
Mesiobuccal cusp rests in the mesiobuccal groove
Class II (retrognathic)
Mesiobuccal cusp is mesial or anterior to the mesiobuccal groove.
Class III (prognathic)
Mesiobuccal cusp is distal or posterior to the buccal groove.
32. OCCLUSION
Normal occlusion can be
defined when the
mesiolabial cusp of the
maxillary first molar
approximates the
buccal groove of the
mandibular first molar.
33. OCCLUSION
Angle’s Classification
Position of the maxillary
and mandibular first molars
Class I: (normal)
Mesiobuccal cusp rests in
the mesiobuccal groove
34. OCCLUSION
Angle’s Classification
Position of the maxillary
and mandibular first molars
Class II (retrognathic)
Mesiobuccal cusp is mesial
or anterior to the
mesiobuccal groove.
35. OCCLUSION
Angle’s Classification
Position of the maxillary
and mandibular first molars
Class III (prognathic)
Mesiobuccal cusp is distal or
posterior to the buccal
groove.
39. ANATOMY
mandible - lower jaw bone
there is a left and a right mandible
have joints - allow the mouth to
open and close
have a hollow canal - nerves and
blood vessels are housed
40. ANATOMY
U – shaped body
Vertically directed
rami
Coronoid
Condyle
Oblique line
Mental foramen
42. ANATOMY
Body - From the distal symphysis to a line
coinciding with the alveolar border of the
masseter muscle (usually including the third
molar) (30-40%)
Angle - Triangular region bounded by the
anterior border of the masseter muscle to the
posterosuperior attachment of the masseter
muscle (usually distal to the third molar) (25 -
31%)
Condyle - Area above the ramus region (15 -
17%)
43. ANATOMY
Symphysis - Region of the central incisors that runs
from the alveolar process through the inferior border
of the mandible (7 - 15%)
Ramus - Part of the mandible that is bounded by the
superior aspect of the angle (3-9%)
Alveolar process - Region of the mandible that
carries the teeth (2 - 4%)
Coronoid process - Includes the coronoid process of
the mandible superior to the ramus region (1 - 2%)
44. INNERVATION
CNV3, the
mandibular n.,
through the foramen
ovale
Inferior alveolar n.
through the
mandibular foramen
Inferior dental plexus
Mental n. through the
mental foramen
45. INNERVATION
CNV3, the
mandibular n.,
through the foramen
ovale
Inferior alveolar n.
through the
mandibular foramen
Inferior dental plexus
Mental n. through the
mental foramen
47. MUSCULATURE:JAW ELEVATORS
Masseter: Arises from
zygoma and inserts into
the angle and ramus
Temporalis: Arises
from the infratemporal
fossa and inserts onto the
coronoid and ramus
Medial pterygoid:
Arises from medial
pterygoid plate and
pyramidal process and
inserts into lower
mandible
48. MUSCULATURE: JAW DEPRESSORS
Lateral pterygoid:
lateral pterygoid plate to
condylar neck and TMJ
capsule
Mylohyoid: mylohyoid
line to body of
hyoid
Digastric: mastoid notch
to the
digastric fossa
Geniohyoid: inferior
genial tubercle to
anterior hyoid bone
49.
50. FAVORABLE FRACTURES
Those fractures where
the muscles tend to
draw fragments
together
Ramus fractures are
almost always
favorable as the jaw
elevators tend to
splint the fractured
bones in place
52. UNFAVORABLE FRACTURES
Fractures where the muscles tend to draw
fragments apart
Most angle fractures are horizontally unfavorable
Most symphyseal/parasymphyseal fractures are
vertically unfavorable
53.
54. ANATOMY
back part of the jaw is
covered with muscles that
are used to open and close
the mouth
teeth of the mandibles and
maxilla usually
interdigitate or have good
occlusion
teeth are rooted in sockets
in the mandible and
maxilla
62. DIAGNOSIS
ROS: bone disease, neoplasia, arthritis, CVD,
nutrition and metabolic disorders, endocrine d/o
TMJ and ankylosis
MVA >> compound, comminuted fractures
Fists >> often single, non displaced fractures
An angled blow to the parasymphysis >>
contralateral condylar fractures
An anterior blow to the chin >> bilateral condylar
fractures
63. PHYSICAL EXAM
Change in occlusion is highly diagnostic
Anterior open bite suggestive bilateral condylar or angle
fractures
Posterior open bite common with alveolar process or
parasymphyseal fractures
Unilateral open bite with ipsilateral angle or
parasymphyseal fracture
Retrognathic (Angle III) seen with condylar or angle
fractures
Prognathic (Angle II) seen with TMJ effusion
64. PHYSICAL EXAM
Anesthesia of lower
lip :“pathognomonic” of a fracture
distal to the mandibular foramen
The converse is not true: not all
fractures distal to the mandibular
foramen have mental n. anesthesia
Trismus of less than 35mm also
highly suggestive of mandibular
fracture
65. PHYSICAL EXAM
Inability to open the mandible
suggests impingement of the
coronoid process on the
zygomatic arch
Inability to close the mandible
suggests a fracture of the
alveolar process, angle, ramus
or symphysis
67. PHYSICAL EXAMINATION
Pertinent physical findings are
limited to the injury site.
Change in occlusion may be evident
on physical examination.
highly suggestive of mandibular
fracture.
Ask patient to compare postinjury
and preinjury occlusion.
70. LACERATIONS AND ECCHYMOSIS
Mandibular fractures can often be
directly visualized beneath facial
lacerations.
Lacerations should be closed after
definitive therapy of the fracture
Ecchymosis is diagnostic of
symphyseal fractures
74. PALPATION
The mandible should be palpated
with both hands, with the thumb
on the teeth and the fingers on the
lower border of the mandible.
Slowly and carefully place
pressure, noting the characteristic
crepitation of a fracture
76. PHYSICAL EXAMINATION
Posttraumatic premature posterior dental contact
(anterior open bite) and retrognathic occlusion may
result from a mandibular angle fracture.
Unilateral open bite deformity is associated with a
unilateral angle fracture.
Anesthesia, paresthesia, or dysesthesia of the lower lip
may be evident.
77. PHYSICAL EXAMINATION
Most nondisplaced mandible
fractures are not associated with
changes in lower lip sensation;
Displaced fractures distal to the
mandibular foramen (in the
distribution of the inferior
alveolar nerve) may exhibit these
findings.
78. PHYSICAL EXAMINATION
Loss of the mandibular angle on palpation may be
because of an unfavorable angle fracture in which the
proximal segment rotates superiorly.
The anterior face may be displaced forward, causing
elongation.
79. PHYSICAL EXAMINATION
Do not close facial lacerations before treating underlying
fractures except in the case of life-threatening
hemorrhage.
Pain, swelling, redness, and localized calor are signs of
inflammation evident in primary trauma.
80. PHYSICAL EXAMINATION
Change in facial contour
loss of external mandibular form
may indicate mandibular fracture.
An angle fracture may cause the
lateral aspect of the face to appear
flattened.
82. RADIOGRAPHIC EXAM
Panorex shows the entire mandible, but requires the
patient to be upright.
It also has particularly poor detail of the TMJ and medial
displacement of the condyles
AP - ramus and condyle
Submental - symphysis
CT - condylar fractures
83.
84. Panoramic radiograph 12 weeks after cancellous iliac crest bone graft with
reconstruction plate showing bony union
85. IMAGING STUDIES:
The single most informative radiologic study used in diagnosing mandibular
fractures is the panoramic radiograph.
Panorex provides the ability to view the entire mandible in one radiograph.
Panorex requires an upright patient, and it lacks fine detail in the TMJ,
symphysis, and dental/alveolar process regions.
Plain films, including lateral-oblique, occlusal, posteroanterior, and
periapical views, may be helpful.
The lateral-oblique view helps in diagnosing ramus, angle, or posterior body
fractures. The condyle, bicuspid, and symphysis regions often are unclear.
Mandibular occlusal views show discrepancies in the medial and lateral position of
the body fractures.
Caldwell posteroanterior views demonstrate any medial or lateral displacement of
ramus, angle, body, or symphysis fractures.
CT scanning may also be helpful.
CT scanning allows physicians to survey for facial fractures in other areas,
including the frontal bone, naso-ethmoid-orbital complex, orbits, and the entire
craniofacial horizontal and vertical buttress systems.
Reconstruction of the facial skeleton is often helpful to conceptualize the injury.
CT scanning is also ideal for condylar fractures, which are difficult to visualize.
92. STUDY BY JAMES, ET. AL.
Prospective study of 422 pts
Infection rate 7%
50% of infections associated with fractured or
carious teeth
ORIF led to 12% infection rate
Staph, strep, bacteroides
Prophylaxis, tooth extraction
93. BONE HEALING
Reactive Phase
Fracture
Formation of granulation
tissue
Reparative phase
Replacement of granulation
tissue by callus
Connective tissue + cartilage
Replacement of callus by
lamellar bone
Remodeling phase
Remodeling of bone to
normal contour
The amount of callus formation is
indirectly proportional to the degree
of immobilization
94. GENERAL
PRINCIPLES OF
TREATMENT
The general physical
status should be
thoroughly evaluated.
40% associated with
significant injury, 10%
of which are lethal
Cerebral contusion is
common
ABC’s!
Almost never
emergent
95. GENERAL PRINCIPLES
Dental injuries should be treated
concurrently
Reestablishment of occlusion is the
primary goal
Fractured teeth may jeopardize
occlusion
Mandibular cuspids are cornerstone
of Tx
Prophylactic antibiotics
97. MANDIBULAR FRACTURES
Dentoalveolar injuries
Cautious use of intermaxillary fixation
Pattern of injuries with condyle most frequently
injured
Possible growth disturbance
High osteogenic potential
Rare complications
98. PRINCIPLES OF JAW FRACTURE
REPAIR
Alignment of the jaw - teeth line up in normal position
is critical for healing of the fracture
Remove all loose teeth or teeth that have periodontal
disease at the level of the fracture
99. PRINCIPLES OF JAW FRACTURE
REPAIR
If the tooth root has been involved a
root canal procedure may be required
Careful suturing of gums
100. MANDIBULAR FRACTURES
Physical Exam
Observance of mandibular range of motion
and malocclusion
Radiographic assessment
Greenstick common
Types of condylar fractures
*especially for kids
101. CLOSED REDUCTION
Grossly comminuted fractures
Significant tissue loss
Edentulous mandibles
Fractures in children
Condylar fractures
Contraindicated in SzDo, psych, and
compromised pulmonary function
102. OPEN REDUCTION
Displaced, unfavorable fractures of angle
Displaced unfavorable fractures of the body or
parasymphysis, as these tend to open at the
inferior border, leading to malocclusion
Multiple fractures of facial bones
Displaced, bilateral condylar fractures
103. CLOSED REDUCTION : DENTULOUS
PATIENT
Erich Arch Bars. Can lead to
periodontal infalmmation.
Avoid fixating incisors, as these
teeth are moved by the wires
Ivey loops
104. CLOSED REDUCTION :
PARTIALLY EDENTULOUS
PATIENT
Partials and circum wires or screws
Acrylic partials with incorporated arch bar
wires
105. CLOSED REDUCTION :
EDENTULOUS PATIENT
Dentures with circum wires and screws
Fabricated acrylic plates (Gunning Splints)
In fractures of both the mandible and maxilla,
circumzygomatic and circum-mandibular wires
should be tied together to prevent telescoping of
maxilla
107. ORIF
Performed with compression plates and lag
screws
MMF generally not required
Eccentrically placed holes and screws placed at
angles “compress” the bone
109. When double fractures occur, they are
usually on contralateral sides of the
symphysis.
Common combinations include the angle
plus the contralateral body or condyle.
Triple fractures occasionally occur, - most
common type is fracture of both condyles
plus the symphysis.
110. The mandible may also be
dislocated without fracture,
sometimes spontaneously
during a large yawn.
patient usually presents with
considerable pain.
Spasm in the masseter and
pterygoid muscles tend to force
the condyles up the anterior
slope of the articular eminence
and prevent normal mouth
closure.
111. AO/ASIFAO/ASIF
“Arbeitsgemeinschaft fur Osteosynthesefragen”
The Association for the Study of Internal
Fixation
Davos, Switzerland
Foundation providing clinical and scientific
research relevant to trauma care for injuries of
the musculoskeletal system
Purpose: Rigid internal fixation with resultant primary bone
healing, even under conditions of full functional loading
112. INTERNAL RIGID FIXATION
Advantages
Early active pain-free functional
movement
Avoidance of intermaxillary fixation
Safe, secured airway without
tracheotomy
Earlier return to work
113. INTERNAL RIGID FIXATION
Interfragmentary compression
Increased friction between fragments
Increased surface area of direct contact
Primary bone healing
No evidence of pressure necrosis
Loose hardware acts only as foreign
body
114. CHAMPY’S IDEAL LINES OF
OSTEOSYNTHESIS
Masticatory muscles produce tension at upper
border and compression at lower border
Torsional forces produced anterior to the
canines
115. CHAMPYCHAMPY
Monocortical “tension banding” osteosynthesis
neutralizes distraction and torsion during physiologic
stress, while normal basilar compression is restored
116. DYNAMIC COMPRESSION Compression resulting in
preload and friction
Preload prevents
distraction
Friction resists torsional
forces
Closure results only
underneath plate
Gap on opposite side
Allows for primary
healing
Contraindicated in
comminution
117. REDUCTION – GENERAL REMARKS
Restoration of occlusion with IMF
Selection of access
Fracture type and location
General anesthesia
Nasal vs. tracheotomy
Tension bands
Bicortical screws
Monocortical to avoid tooth roots and mandibular
nerve
Compression and reconstruction plates
Inferior margin
Bicortical screws
132. CONDYLE PROCESS
Classified according to Kohler
(1951)
Condylar fracture line runs
inside capsule of TMJ
Not fixed with plates or screws
Subcondylar situated below the
capsule
Classified into high and low
Condylar base fractures are at
level of the sigmoid notch
(incisura semilunaris)
135. RAPID IMF
Advantages:
Easy insertion, OR time ≈ 10
minutes
Removal without anesthesia
Minimal danger to surgeon
Decreased damage to dental
papillae and oral mucosa
Easier to maintain dental
hygiene
Compatible with all rigid
plating systems
137. RAPID IMF
Roccia, Fasolis et al.
An Audit of Mandibular Fractures Treated by
IMF Using Intraoral Cortical Bone Screws
Journal of Crani-maxillofacial Surgery
Turin, Italy 2005
138. RAPID IMF
ORIF 44 patients
CR 18 patients
Occlusion 2-3 weeks
Screws removed under local only
Minimum 6 month f/u
Oral mucosa
covering screw
5%
Lost screws 2%
Dental root
injury
11%
Infection 1%
Malocclusion < 1%
139. RAPID IMF CONCLUSIONS
• Recommended:
– Single or double fractures with minimal displacement
– Compound condylar fractures
– Edentulous patients if proper dentures available
• Contraindicated:
– Multiple comminuted fractures
– Alveolar bone fractures
– Pediatric patients with unerupted teeth
– Severe osteoporosis
140. POSTOPERATIVE ANTIBIOTICS
Abubaker et al.
Medical College of Virginia
J Oral Maxillofac Surg. 2001
Prospective, randomized, double-blind,
placebo-controlled study
30 patients, 2 arms, 6 week post-op f/u
** No significant statistical difference between groups
141. ORIF VS. MMF
TMJ FUNCTION ANALYSIS
Gorgu, Erdogan et al.
Scand J Plast Reconstr Surg Hand Surg 2002
Ankara, Turkey
Prospective Comparative Study of the Range of
Movement of TMJ After Mandibular Fractures:
Rigid or Non-rigid Fixation
142. GORGU, ERDOGAN ET AL.
Prospective, randomized, controlled study
147 patients in 3 groups (1993-1998)
MMF= 54
4 weeks immobilization
Titanium miniplate ORIF= 49
No movement restriction
Control= 44
Randomly selected with no hx of mandible injury
Mean follow-up 2.2 yrs (1-3)
Exclusion criteria
Condylar frx, multiple frx, comminution or
significant displacement, malocclusion, edentulous
143. GORGU, ERDOGAN ET AL.
MMF *
(n=54)
ORIF **
(n=49)
Controls
(n=44)
Max jaw opening (mm) 30.9 (6.0) 45.1 (5.9) 50 (5.4)
Max displacement to
left (mm)
8.0 (2.9) 9.9 (2.4) 11 (2.5)
Max displacement to
right (mm)
6.8 (3.3) 9.6 (2.3) 10 (2.6)
Protrusion (mm) 3.4 (1.5) 9.3 (0.8) 10 (1.0)
* p < 0.001 compared with control
** p < 0.001 compared with control and MMF group
144. GORGU, ERDOGAN ET AL.
Trauma is major factor leading to TMJ dysfunction
MMF increased the incidence and severity of TMJ dysfunction
MMF *
(n=54)
ORIF **
(n=49)
Controls
(n=44)
Click 38 (70%) 20 (41%) 11 (25%)
Crepitus 36 (67%) 11 (22%) 5 (11%)
* p < 0.003 compared with control
** p < 0.005 compared with control and MMF group
145. ORIF VS. MMF
COMPLICATION ANALYSIS
Moreno et al.
J Oral Maxillofac Surg 2000
Madrid, Spain
Complication Rates Associated with
Different Treatments for Mandibular
Fractures
146. MORENO ET AL. Retrospective study
245 patients with 386 fractures (1993-1996)
Isolated condylar process fractures excluded
Treatment methods:
MMF (n=136)
Exclusive, 40 days occlusion
2-mm miniplates (n=45)
Post-op MMF 0 – 15 days
AO 2.4 mm system (n=19)
Immediate mobility
AO 2.7 mm system (n=32)
Immediate mobility
Severity scale, multiple variables analyzed
147. MORENO ET AL
Rate of postoperative infection for each type of
treatment, separated by severity of fractures
0
25
50
75
100
MMF 2 mm AO 2.4 AO 2.7
1
2
3
4
Severity
*p < 0.001 between infection rate and fracture severity only
148. MORENO ET AL
Rate of postoperative malocclusion for each type of
treatment, separated by severity of fractures
0
25
50
75
100
MMF 2 mm AO 2.4 AO 2.7
1
2
3
4
*p < 0.05 between malocclusion rate and fracture severity only
Severity
149. MORENO ET AL
Overall complication rate for each type of treatment,
separated under severity of the fractures
0
25
50
75
100
MMF 2 mm AO 2.4 AO 2.7
1
2
3
4
*p < 0.001 between overall rate and fracture severity only
Severity
150. ORIF
POST-OP MMF VS. IMMEDIATE
MOBILIZATION
B Kaplan, S Park et al.
Laryngoscope 2001
Univ of Virginia Medical Center
Immediate Mobilization Following Fixation
of Mandible Fractures
151. PARK ET AL.
Prospective, randomized, single-blinded study
ORIF 2.0 mm titanium plates
Inclusion: displaced fractures between angles only
29 patients in 2 groups (1997 – 2000)
Immediate function (n=16)
2 weeks post-op MMF (n=13)
Follow-up intervals: 3 wks, 3 mos, 6 mos
Variables assessed by surgeon blinded to the
history of immobilization
Pain, non-union, malunion, occlusion, trismus,
infection, weight loss, dental hygiene
152. PARK ET AL.
No statistical difference between measured variables
The assumed beneficial effects from transient TMJ rest
and no fracture stresses was not realized
Wt loss in pounds
Objective trismus in cm
153. ORIF VS. MMF
COST ANALYSIS
B Schmidt, L Kaban et al.
J Oral Maxillofac Surg 2000
University of California San Francisco
A Financial Analysis of MMF vs. Rigid
Internal Fixation for Treatment of
Mandibular Fractures
154. KABAN ET AL.
Retrospective study
85 patients in two groups
CRF (n=38)
ORIF (n=47) (external and transoral approaches)
Outcome variables:
Length of hospital stay
Duration of anesthesia
Surgery time
Patient fee for primary treatment without
complications
Estimated average patient fee to manage a major
post-op infection
155. KABAN ET AL.
CRF ORIF
Preop hospital days 1.79 1.98
Postop hospital days 1.95 2.56
*Anesthesia time
(min)
141 309
*Surgical time
(min)
106 267
*p < 0.0001
156. KABAN ET AL.
Did not evaluate savings from earlier return to
work in ORIF patients
Charge for
primary
treatment
Charge for
complication*
Total
charg
e
CRF $10,099 ±
5,489
$26,671 ± 2,310 $10,9
26
ORIF $28,361 ±
14,731
$39,212 ±
38,694
$34,6
35
P-
value
< 0.001 < 0.0652 < 0.001
* Incidence of post-op infx was 16% (ORIF) and 3%(MMF)
157. CLOSED TECHNIQUES
Nondisplaced favorable fractures
Grossly comminuted fractures
Edentulous fractures (using a mandibular
prosthesis)
Fractures in children with developing dentition
Coronoid and condylar fractures
158. INDICATIONS FOR OPEN
REDUCTION
Displaced unfavorable angle, body, or
parasymphyseal fractures
Multiple facial fractures
Bilateral displaced condylar fractures
Fractures of an edentulous mandible (with severe
displacement of fracture fragments in an effort to
reestablish mandible continuity)
159.
160. Grafted right mandibular body nonunion
with cancellous iliac crest bone graft,
packed into polyglactin mesh tube.
161. Grafted left mandibular body nonunion
with cancellous iliac crest bone graft
packed into polyglactin mesh tube.
162. CONCLUSIONS
AO does not mean “always operate” or “always
open”
AO standards provide sound techniques resulting
in a consistently high success rate in most hands
Occlusion must be 100% prior to rigid internal
fixation
Main indications for RIF include:
Compound fractures with defects
Edentulous mandibles or those with few teeth
Fracture dislocation ± condylar neck fracture
Panfacial trauma
Electively
163. WISE SAYINGS ABOUT
MANDIBULAR FRACTURES
Remember the ring bone rule.
Symphyseal fractures can be diabolically hard to see, even on a well-
exposed AP film
Remember the Panorex view -- this can usually only be taken by a special
machine in the oral surgery department, but it provides the best single view
of the mandible and will show you fractures that cannot be seen by any
other method short of CT.
Look carefully along the cortical margin of the whole mandible for
discontinuities. This may be the only sign of a fracture that you will see.
164. WISE SAYINGS ABOUT
MANDIBULAR FRACTURES
Also carefully examine the mandibular canal for
discontinuities.
A fracture line entering the root of a tooth is considered an
open fracture by definition.
Pathologic fractures can occur in the mandible. Look carefully
for evidence of a periapical abscess or a mandibular tumor,
especially if there doesn't seem to be enough trauma to match
the injury.